In conclusion...

Thanks for coming to my blog all this week. I've tried to give you an idea of what I thought the most interesting things were at this year's Scientific Sessions.

We had a brand new feature this year that was a rousing success. We had 9 top experts in diabetes who attended many different sessions throughout the meeting, saw many different posters and oral abstracts. They gave their impressions of highlights of the meeting this morning. We were excited at how this new session went and we're pretty sure we will add it to the program in years to come.

Instead of me telling you what they said were the best things that took place during the meeting, I invite you to go for free to check these sessions out for yourself. Both of these sessions (Basic Science Highlights and Clinical Science Highlights)will be available as a free webcast on our site in just a few days. I encourage you to check them out at www.diabetesconnect.org.

Thanks again for reading along. See you next year in Chicago.

Intensive therapy and cognitive ability

In the late-breaking clinical trials syposium, where the results of clinical trials that have recently come to conclusion are presented, we saw an extremely "good news" presentation by the Diabetes Control and Complications group.

As most of you know, the DCCT was reported back in 1993 and showed for the first time that intensive glycemic control significantly reduced the rate of complications for eye disease, kidney disease and neuropathy in people with type 1 diabetes. There was always some concern in the intensively treated group, that the increased frequency of hypoglycemic events - particular sever hypoglycemic events - might have an untoward effect on cognitive function. We know through many studies that intensive control increases hypoglycemnic events and people were worried that, over the long term, such events would have a negative effect on learning and cognitive function.

The great news is that after an average of 18 years of follow-up and careful analysis of cognitive function, there was no association between any cognitive change and the A1C values achieved in the study. In other words, even those people with the very best control and a higher frequency of hypoglycemic events, were not associated with any cognitive change.

People who want to achieve low blood glucose can do so without worrying that an increase in hypoglycemic events will affect their brain function. This highlights that improved glycemic control with intensive therapy is well worth it.

Bariatric surgery

There was an interesting but discouraging session on Monday in which one study reported higher death rates in people who seek bariatric surgery. This procedure, of course, is only recommended for those who are exceedingly obese. Although we had some encouragement that such therapy could be helpful, we're now seeing reports that the new cases of coronary heart disease is much greater than anticipated. Another surprise is that the suicide rate of those who have received this procedure is higher than one might expect to see in the general population.

A key issue may be that in the early days of bariatric surgery there was not long-term and careful follow-up. Now we realize that there needs to be careful follow-up of these patients to assure appropriate diet and exercise as well as counseling for depression and body image problems. Also on Monday there was another presentation showing that bariatric surgery and weight loss may have a significant negative effect on bone health.

So all told, as we know from virtually all procedures in medicine, there can be benefits but also adverse consequences to bariatric surgery. People who are morbidly obese may lose a lot of weight following the surgery, but in the long term they may also sufffer other adverse effects. The trade-off between the two should be carefully considered by those contemplating the treatment and their health care teams.

Exhibit hall

This year's exhibit hall is very impressive. Over 200 companies and organizations are represented, each showing their latest products and services as well as future supplies and devices that are in the pipeline. It's a great opportunity for the attendees to get a good feel for what's available and what's coming.

You can go here to learn more about the companies exhibiting at this year's Scientific Sessions.

Elevated blood glucose in the ICU

This morning we heard the results of a major study that enrolled 216,000 critically ill patients in the greater Cincinnati area. The investigators showed that patients admitted to intensive care units with an elevated blood glucose had a greatly increased rate of mortality compared to people without an elevated blood glucose.

Other studies over the last few years have shown the same phenomenon, but this was the largest study ever done on the subject.

Here again we have convincing evidence that an elevated blood glucose may be a surrogate measure for other things that are going on in the body.

Taste

There was a great symposium on taste receptors. You may think this is strange to be at a meeting on diabetes, but it turns out to be very relevant to diabetes and the obesity epidemic we're seeing. You know that we have four taste receptors - sweet, sour, bitter and salty. Now in this symposium, one speaker showed compelling evidence that we may have a fifth taste receptor for fat.

It may be a natural thing to have. Thousands of years ago perhaps a taste receptor for fat made humans seek out foods that had a high-concentration of fat. Fat provides more energy per gram than other food substances and can be easily stored in the body for later use. This was more necessary then, when perhaps it was unknown when the next meal would be available.

But nowadays, we can eat every half-hour so we may not need the fat receptor for taste, but it seems like we have it anyway. Maybe that explains why foods that contain fat - usually the high-density, high-caloric foods - are the ones we often crave.

Another speaker showed that the stomach may have taste receptors as well. So not only does taste affect us in our mouths but our stomachs may "taste" our foods and cause hunger for certain kinds of food.

Taste receptors and how we deal with food may play a very important role in the obesity epidemic and that means an important role in the development of diabetes.

Prediabetes as a precursor

There were a number of talks on Sunday on the state of "prediabetes." Also called "impaired fasting glucose" or "impaired glucose tolerance," really it's an elevated blood glucose - above normal but not yet in the range where we would diagnose someone with diabetes.

It's turning out that this state of mildly elevated blood glucose not only predicts the onset of diabetes but is also associated with hypertension in some individuals, abnormal lipid levels in other individuals, and it may be associated with the development of some cancers.

This state of elevated blood glucose may not just simply be a harbinger of diabetes but may be indicative of some underlying abnormality that may have ramifications for a lot of different diseases. Elevated blood glucose is likely due to something called "insulin resistance" - the inability of insulin to work properly in the body. When an individual has insulin resistance and their beta cells don't work, they'll likely get diabetes. If they have insulin resistance and some other factor, maybe you'll develop hypertension. If another factor becomes abnormal, maybe they develop colon cancer or breast cancer.

Unfortunately, as with blood pressure, insulin resistance tends to increse with age. It's also greatly influenced by one's genetics. But there may be ways to treat insulin resistance. We know, for instance, that losing weight and exercising reduces insulin resistance in our bodies.

We need to pay particular attention to insulin resistance because it can really be a harbinger of adverse health consequences down the road.

A new commitment to diabetes care

Every year at the Scientific Sessions, ADA's President gives a keynote address. This year Dr. Robert Rizza from the Mayo clinic talked about the impact of finding a cure for diabetes and treating diabetes as appropriately as possible.

He titled his address "Cure, Care, and Commitment" and it was really a dramatic demonstration of the imapct of diabetes in America if not the whole world. Insofar as a cure is concerned, he discussed the impact if we found a cure for diabetes today - that is, everyone with diabetes doesn't have it anymore; those who are just about to get diabetes do not; and children born tomorrow would never see the disease.

Using results from a recent study he conducted with a phenomenal computer-based mathematical model called Archimedes, Dr. Rizza showed the impact of different diabetes scenarios. As he pointed out in his address, Archimedes is extremely complete and robust. Basically it is a virtual healthcare system - virtual patients getting virtual symtoms, visiting virtual doctors, getting virtual tests and procedures. Some of the virtual patients have adverse outcomes and have to go to virtual hospitals. It's sort of a SIM City for healthcare. To show its accuracy, Archimedes has been trial-validated, meaning it has predicted results of clinical trials without using any of the trial findings.

Using Archimedes, Dr. Rizza showed that if diabetes were cured today there would be a dramatic reduction in a wide variety of adverse consequences associated with diabetes. It would reduce the number of such serious life-changing complications by 1.4 million per year.

While it's nice to consider, and a cure for diabetes is obviously the longer-term goal, Dr. Rizza asked "what if we in the medical community committed ourselves to achieving every single ADA goal in all of our patients?" Every patient would have an A1C less than 7, a blood pressure less than 130/80, and LDL less than 100, etc. If everyone were like that, what would be the impact? Archimedes tells us that the impact would be tremendous - 8 million fewer heart attacks, 1.6 million fewer strokes, 2.2 million fewer episodes of kidney failure, 2.4 fewer cases of blindness or eye surgery, 100,000 fewer amputations and 3.5 million fewer deaths resulting in 18 million fewer life-changing serious diabetes complications during the next 30 years – and a savings of over $325 billion in medical care costs.

Of course it may not be feasible to get 100% of diabetes patients to goal. What if we had 80% at goal. Here too, Dr. Rizza showed the numbers are dramatic. Even this more feasible goal would have a tremendous effect on healthcare. Of course bringing patients down to these goals - more drugs, an extra office visit, more supplies, etc - comes with additional costs. But extra expense is offset by the savings seen through the reduction of complications.

Lastly, Dr. Rizza proposed a simple approach. Give everyone metformin, a low-dose aspirin, an LDL-lowering statin and a ACE-inhibitor to lower blood pressure. This "poly-pill" would cost $100-$200 per year per patient. Just giving this treatment to every person with diabetes would save the US healthcare system an enormous amount of money and would have a dramatic effect on complications. The risk of heart attacks during the next 30 years would be reduced by 50%, renal failure by 4%, blindness and eye surgery by 33%, and total serious diabetes complications by 35%.

Before nearly 8,000 medical professionals and researchers, Dr. Rizza produced thunderous applause by dramatically showing that if we spend time, money and energy to prevent the complications rather than focusing on treating them, you save a lot of money and of course save lives and prevent suffering. It was a tremendous talk and its message resonated well with the entire audience.

Unite for Diabetes

The International Diabetes Federation has launched a new campaign called "Unite for Diabetes." The campaign aims to highlight the alarming rise of diabetes worldwide and to encourage government support for a United Nations Resolution on diabetes.

New data from the IDF show that more than 230 million people, almost 6% of the world's adult population, now live with diabetes. Every 10 seconds a person dies from diabetes-related causes and the death rates are predicted to rise by 25% over the next decade.

Reversing the current trend is imperative and it will require the attention and dedication of the international community. A United Nations Resolution on diabetes will recognize the global burden of diabetes the need for immediate action.

The American Diabetes Association supports the Unite for Diabetes campaign.

Insulin and longevity

A fascinating syposium Sunday morning dealt with the intrinsic value of the insulin pathways. Insulin is of course in our bodies - it's produced by insulin-secreting cells and it affects our metabolism. The question is why do we have these molecules to begin with? What do they really do?

To answer these questions, scientists have gone back to some primitive forms of life. One of these is a small worm - not the kind of garden worm we're all used to seeing - but a microscopic worm which only has a small number of genes and a few hundred cells in its entire body. These scientists have looked at the metabolic pathways in this worm and found that pathways related to insulin are important in metabolism (not a surprise) and aging (that is a surprise).

In worms in which they altered the genes related to insulin, the worms lived twice as long as normal worms. That's a pretty impressive difference. It may be due to the way changing this gene influences what the worm eats and how it metabolizes its food.

In many reports over the years, people have hypothesized that caloric restriction - really trying to stay lean - is felt to influence logevity. It may do so by affecting the way insulin works in the body and the level at which it is secreted. Perhaps as we eat less and don't put on as much weight, we affect the way insulin works in the body and by manipulating those pathways, we may influence longevity.

Endocannabinoids

Almost everyone is aware of the phenomenon that smoking marijuana can cause extreme hunger - "the munchies". This effect is due to a chemical reation in the body. Recently scientists have looked more closely at these kinds of reactions by examining the body's endocannabinoid system. The endocannabinoid system is a whole new set of pathways involved in satiety (feeling full) and hunger. These pathways have a major influence in what we eat and when we feel full.

Findings presented here showed that if you inhibit this system, people will feel full and subsequently lose weight. In addition to that, it turns out the endocannabinoid system is very important in influencing blood pressure and lipid values as well as satiety. Some very promising new drugs are being developed that may influence this system and produce the benefit of weight loss and improved cardiovascular risk factors. Hopefully we'll hear more about these drugs and perhaps see one on the market in the near future.

But perhaps even more exciting is the fact that, whereas we thought things were complex already in the relationship between hunger and satiety, they have become even more complex with the discovery that we have a whole new system of pathways involved in eating and feeling full. The more pathways we know about the better chance we have of developing tools to fight the epidemic of obesity.

Pregnancy and physical activity

Also on Saturday, there was a study presented using data from the National Maternal and Infant Health Survey which measures physical activity before and during pregnancy.

Looking at many thousands of women, a significantly lower percentage of women who reported physical activity during pregnancy developed gestational diabetes compared to those who were inactive during their pregnancy.

Amongst all the things that doctors have told pregnant women to do like "don't drink too much alcohol" and certainly "don't smoke," we should really emphasize physical activity during prenancy as a way to reduce the liklihood of developing gestational diabetes.

Lose weight by eating...breakfast

There was a fascinating story on Saturday about the virtues of eating breakfast on obesity. Scientists did a careful study of adolescents, studying those who skip breakfast compared against those who eat a complete breakfast daily. It seems that independent of the body weight of their parents, family history of diabetes, etc., those people who skipped breakfast were heavier than those people who ate breakfast. This suggests that breakfast-eating in some fashion influences body weight.

Investigators speculated in their presentation that it really wasn't the breakfast or the skipping of it per se. Rather if you don't eat breakfast, you tend to get hungry and snack. Eating breakfast allows you to avoid snacking, which is often high-density, high-caloric foods. In addition, they suggest that missing breakfast might be associated with poor eating habits of the family. Rather than everyone eating breakfast and dinner together, people go their own way with easy and inexpensive access to snack foods.

Moral: Eating a good breakfast and developing healthy eating habits from the first meal of the day can help reduce your risk of being overweight.

Oral insulin?

There was a very interesting presentation yesterday about "insulin by pill."

Over the years, many companies have tried to formulate insulin in pill form. The problem is that insulin is a protein and, when ingested, it gets broken down by the digestive system and does not retain the biological effect that we want.

Now we have a company that has just started to make a coated insulin that has about 60-70% of the potency of injected insulin. This is higher than previous attempts to make an oral insulin molecule and it holds a lot of promise.

We've been down this road before with other coated insulins and, for one reason or another, they have not turned out to work nearly as well as injected insulin. But I am hopeful.

Certainly we won't see this pill available in the next year or two, but I think we can cross our fingers and hope that before the close of this decade we could do away with injected insulin and have the molecule in pill form.

The new A1C

Everyone knows that the A1C test measures long-term glycemic control over the previous 3 months. The test is valuable as a predictor of diabetes-related complications and improved A1C measures result in reduced complications. And we all know that everyone with diabetes should have an A1C below 7, and that normal is in the range of 4-6. Right? Well, maybe not for long.

Now a new reference method for measuring A1C is about to come on the scene and the normal test range will be about 2% lower than the current method. Will this cause confusion after decades-long professional and public education efforts emphasizing that the goal of control is an A1C less than 7%? Should the name of the test be changed to avoid confusion and the results reported as “average blood glucose” rather than as a percent? There’s a LOT of activity going on behind the scenes on this issue, including a major effort by ADA and other groups to look at the true correlation between A1C and mean blood glucose, with the possibility that we’ll switch to the new terminology in the future.

With two major studies going on trying to relate the "ABG" to "A1C," along with the move of the International Federation of Clinical Chemistry to change the terminology and values related to the test, one thing is almost certain: In another couple of years we may not have something called "A1C," nor test results between 4 - 12%.

Call to Congress

I wanted to highlight another important activity that took place here in Washington this past week. On Thursday, over 500 Diabetes Advocates rallied on Capitol Hill and met with their senators and representatives. They urged Congress to increase federal funding for diabetes research and prevention at both NIH and CDC, as well as pass the Stem Cell Research Enhancement Act.

This was a great showing of passion around these two issues that are extremely important to people with diabetes.

How good is "good" cholesterol?

This morning there was an interesting symposium focusing on blood lipids - specifically on HDL, the "good" cholesterol. In contrast to LDL which we want to keep low, a higher HDL measurement is beneficial to lowering one's risk of heart attack and stroke.

As many of you know, there has been a lot of research and attention paid to driving the LDL number lower. In particular, the focus has been on the use of drugs known as statins. Now it seems that scientists have turned their sights to HDL to try to learn more about it and how good it is.

Interestingly, there are a number of studies coming out that suggest that HDL might be a better target for the prevention of heart attacks than LDL-lowering. The good news is that the drug industry seems to be developing drugs that may become available in the next year or two. These drugs could raise HDL in those individuals whose levels are lower than they should be.

There was a lot of discussion and conversation today about the role of HDL - what causes it to increase and what causes it to not be high enough in some individuals. We know that exercise can raise HDL but it doesn't seem do it as much as pharmacotherapy potentially can.

So it's an interesting issue and it makes the treatment of lipid disorders even more complex.

Clinical inertia

Who's responsible for optimal diabetes care? Is the burden on the doctor or on the patient?

In the first of many studies on this issue to be presented at the meeting, it was shown that doctors are simply not treating diabetes as agressively as they should. When a patient is not doing well, instead of changing the drug regimen or increasing the dosage, they are waiting much too long before taking action. This is clinical inertia.

The study, from a group in Boston, showed that about one-third to one-half of patients studied are going much longer than they should in the same dose of medication when they are not achieving the ADA's recommended goals for therapy.

There are additional studies coming up later from groups in Germany and Baltimore who studied large numbers of patients and came to much the same conclusion - physicians are simply waiting too long.

The moral of the story seems to be that when someone has diabetes, they need to ask questions of their medical team such as "What can I do differently?, Should my medication be increased?" Patients really need to put pressure on their doctor to do more. Get to your doctor if you are not reaching goal - and don't be passive about your diabetes care.

You are what your mother ate

Everyone knows that pregnant women shouldn't consume a lot of alcohol and shouldn't smoke. But are there other factors they should be aware of?

In this study, investigators took pregnant rats and fed one group a high-fat diet, comparable to the typical American diet. They then gave the control group a low-fat diet. After the offspring were born, all the baby rats were fed, by surrogates, the same healthy diet.

Amazingly, 100% of the rats who had a high-fat exposure in utero developed insulin resistance, the first sign of the development of diabetes. None of the control rats did so.

This study suggests that a mother's consumption of a high-fat diet may pre-dispose her children to developing type 2 diabetes later in life. It would follow that pregnant women should avoid a high-fat diet and excessive weight-gain during pregnancy. Of course, these are animal studies, but this was an interesting, well-conducted study and it does point to the fact that a mom's diet during pregnancy can affect the baby's risk for diabetes.

Diabetes and depression

An interesting oral abstract was just presented, the first of many dealing with diabetes and depression. As many of you can probably appreciate, people who have diabetes often get depressed, disappointed and frustrated, not only with diabetes but their life status.

There has been a lot of research, as you might expect, on understanding why this occurs - is it more than just the hardship of diabetes?

What we do know is the prevalence of depression in people with diabetes is much greater that the prevalence of depression in the general population. So the question is - Does diabetes cause depression or does depression cause diabetes?

There are a number of abstracts dealing with depression at the meeting this year. In this first study, a group of people who were diagnosed with diabetes were not told they had diabetes. They were then given a mental health test - a PHQ score - which is a measure of depression. These patients who were not told they had diabetes tended to have normal PHQ values. However, a different group of patients who were diagnosed with diabetes and told so, had lower values indicating that they were depressed about it.

As one might normally expect, it's not the diabetes altered state of metabolism but rather the knowledge that one has diabetes that leads to depression. The general awareness of health risk that is conferred upon people with diabetes may actually contribute to depression.

Excitement in the air

It's thrilling and exciting to see the banners everywhere and the halls crowded with people. It's wonderful to see old friends and meet people from around the world who have come to this meeting. Everyone is eager to hear the presentations and discuss collaborations on a wide variety of research.

Greetings from Washington

Even though I've been to this meeting for 21 straight years, I still get excited about hearing all the latest research and the reviews of important topics.

The ADA meetings have all taken place in June in various cities around the country. But as the meeting has grown - from about 1,800 in 1985 to ver 17,000 today - there are fewer and fewer cities that can accommodate us. In fact, about 50% of the attendees now come from outside the U.S. and we have people coming from over 75 different countries. Amazing.

The sessions start later today in the Washington Convention Center. It's a beautiful new facility with great meeting space and a huge exhibit hall. There is clearly a buzz in the air with all the science that will be presented. More updates throughout the day...

Hello & Welcome

Hi I'm Richard Kahn, Chief Scientific & Medical Officer for the American Diabetes Association. I invite you to join me here as I share news and information from our 66th Annual Scientific Sessions, June 9 - 13 in Washington, D.C.

Each year, the world's top health professionals involved in diabetes research and care come together at this conference to share their knowledge and exchange ideas. I will use this forum to share some of the more interesting research and information presented at this year's conference.